Observation Report

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This form is to be completed if you notice any bruise, mark, scratch, bump, rash, etc.
-OR-
an injury was sustained by a person we serve as a result of an interaction (please attach to the interaction report)

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Details

Individual's full name

Name of the support submitting report

Others Involved

Date observed or occurred

Time observed or occurred (please use AM or PM)

Is this a result of an interaction

Was an Interaction report submitted?

Description of the observation or injury

Briefly describe how the injury was noticed and/or what happened

Medical Attention required

Was person hospitalized or EMS called

Describe other actions taken

Directions provided for ongoing care or observation

I want to have a follow up debriefing session with my coordinator

Supports Signature

Name of supervisor notified if medical attention was required